2 Substance Abuse Treatment: Group Therapy This TIP, Substance Abuse Treatment: Group Therapy, presents an overview of the role and efficacy of group therapy in substance abuse treatment planning. This TIP offers research and clinical findings and distills them into practical guidelines for practitioners of group therapy modalities in the field of substance abuse treatment. The TIP describes effective types of group therapy and offers a theoretical basis for group therapy s effectiveness in the treatment of substance use disorders. This work also will be a useful guide to supervisors and trainers of beginning counselors, as well as to experienced counselors. Finally, the TIP is meant to provide researchers and clinicians with a guide to sources of information and topics for further inquiry. Collateral Products Based on TIP 41 Quick Guide for Clinicians DHHS Publication No. (SMA) Printed 2005 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

5 Acknowledgments Numerous people contributed to the development of this TIP (see pp. ix, xi, and appendices F, G, and H). This publication was produced by The CDM Group, Inc. (CDM) under the Knowledge Application Program (KAP) contract number with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Karl D. White, Ed.D., and Andrea Kopstein, Ph.D., M.P.H., served as the Center for Substance Abuse Treatment (CSAT) Government Project Officers. Christina Currier served as the CSAT TIPs Task Leader. Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP Executive Deputy Project Director. Shel Weinberg, Ph.D., served as the CDM KAP Senior Research/Applied Psychologist. Other CDM KAP personnel included Raquel Witkin, M.S., Deputy Project Manager; Susan Kimner, Managing Editor; James Girsch, Ph.D., Editor/Writer; Michelle Myers, Quality Assurance Editor; and Sonja Easley, Editorial Assistant. In addition, Sandra Clunies, M.S., I.C.A.D.C., served as Content Advisor. Jonathan Max Gilbert, M.A., Susan Hills, Ph.D., and Mary Lou Rife, Ph.D., were writers. Disclaimer The opinions expressed herein are the views of the Consensus Panel members and do not necessarily reflect the official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instruments, software, or resources described in this document are intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA/CSAT or the authors. Do not reproduce or distribute this publication for a fee without specific, written authorization from SAMHSA s Office of Communications. Electronic Access and Copies of Publication Copies may be obtained free of charge from SAMHSA s National Clearinghouse for Alcohol and Drug Information (NCADI), (800) or (301) ; TDD (for hearing impaired), (800) , or electronically through the following Internet World Wide Web site: Recommended Citation Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series 41. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD DHHS Publication No. (SMA) Printed 2005 ii Acknowledgments

6 Contents What Is a TIP?...vii Consensus Panel...ix KAP Expert Panel and Federal Government Participants...xi Foreword...xiii Executive Summary...xv Chapter 1 Groups and Substance Abuse Treatment...1 Overview...1 Introduction...1 Defining Therapeutic Groups in Substance Abuse Treatment...2 Advantages of Group Treatment...3 Modifying Group Therapy To Treat Substance Abuse...6 Approach of This TIP...8 Chapter 2 Types of Groups Commonly Used in Substance Abuse Treatment...9 Overview...9 Introduction...9 Five Group Models...12 Specialized Groups in Substance Abuse Treatment...29 Chapter 3 Criteria for the Placement of Clients in Groups...37 Overview...37 Matching Clients With Groups...37 Assessing Client Readiness for Group...38 Primary Placement Considerations...40 Stages of Recovery...43 Placing Clients From Racial or Ethnic Minorities...44 Diversity and Placement...52 Chapter 4 Group Development and Phase-Specific Tasks...59 Overview...59 Fixed and Revolving Membership Groups...59 Preparing for Client Participation in Groups...61 Phase-Specific Group Tasks...72 Chapter 5 Stages of Treatment...79 Overview...79 Adjustments To Make Treatment Appropriate...79 The Early Stage of Treatment...80 The Middle Stage of Treatment...85 The Late Stage of Treatment...88 iii

8 Figures 1-1 Differences Between 12-Step Self-Help Groups and Interpersonal Process Groups Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models Characteristics of Five Group Models Used in Substance Abuse Treatment Group Vignette: Joe s Argument With His Roommate Joe s Case in an Individually Focused Group Joe s Case in an Interpersonally Focused Group Joe s Case in a Group-As-A-Whole Focused Group The SageWind Model for Group Therapy Eco-Map Client Placement by Stage of Recovery Client Placement Based on Readiness for Change What Is Culture? Diversity Wheel When Group Norms and Cultural Values Conflict Three Resources on Culture and Ethnicity Guidelines for Clinicians on Evaluating Bias and Prejudice Self-Assessment Guide Preparing the Group for a New Member From a Racial/Ethnic Minority Culture and the Perception of Conflict Characteristics of Fixed and Revolving Membership Groups The Family Care Program of the Duke Addictions Program SageWind Examples of Agreements About Time and Attendance Examples of Agreements About Group Participation Reminders for Each Group Session Shame Confidentiality and 42 C.F.R., Part Jody s Arm How Important Is It for a Substance Abuse Group Leader To Be in Recovery? Does Online Communication Impede Attachment? Group Experiential Training Contents v

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10 What Is a TIP? Treatment Improvement Protocols (TIPs), developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (DHHS), are best-practice guidelines for the treatment of substance use disorders. CSAT draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities as alcohol and other drug disorders are increasingly recognized as a major problem. CSAT s Knowledge Application Program (KAP) Expert Panel, a distinguished group of experts on substance use disorders and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs. Topics are based on the field s current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Then recommendations are communicated to a Consensus Panel composed of experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group s collaboration. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. vii

11 The TIPs can be accessed via the Internet at the URL: The move to electronic media also means that the TIPs can be updated more easily so that they continue to provide the field with state-of-the-art information. While each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey front-line information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists clinical experience or the literature. If research supports a particular approach, citations are provided. This TIP, Substance Abuse Treatment: Group Therapy, presents an overview of the role and efficacy of group therapy in substance abuse treatment planning. The goal of this TIP is to offer the latest research and clinical findings and to distill them into practical guidelines for practitioners of group therapy modalities in the field of substance abuse treatment. The TIP describes effective types of group therapy and offers a theoretical basis for group therapy s effectiveness in the treatment of substance use disorders. This work also will be a useful guide to supervisors and trainers of beginning counselors, as well as to experienced counselors. Finally, the TIP is meant to provide researchers and clinicians with a guide to sources of information and topics for further inquiry. viii What Is a TIP?

16 Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA s mission of building resilience and facilitating recovery for people with or at risk for mental or substance use disorders by providing best-practices guidance to clinicians, program administrators, and payors to improve the quality and effectiveness of service delivery, and, thereby promote recovery. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panel s work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped to bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people who abuse substances. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Charles G. Curie, M.A., A.C.S.W. Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration xiii

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18 Executive Summary With the recognition of addiction as a major health problem in this country, demand has increased for effective treatments of substance use disorders. Because of its effectiveness and economy of scale, group therapy has gained popularity, and the group approach has come to be regarded as a source of powerful curative forces that are not always experienced by the client in individual therapy. One reason groups work so well is that they engage therapeutic forces like affiliation, support, and peer confrontation and these properties enable clients to bond with a culture of recovery. Another advantage of group modalities is their effectiveness in treating problems that accompany addiction, such as depression, isolation, and shame. Groups can support individual members in times of pain and trouble, and they can help people grow in ways that are healthy and creative. Formal therapy groups can be a compelling source of persuasion, stabilization, and support. In the hands of a skilled, well-trained group leader, the potential healing powers inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer reinforcement, act as a forum for self-expression, and teach new social skills. In short, group therapy can provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual therapy. Group therapy and addiction treatment are natural allies. One reason is that people who abuse substances are often more likely to stay sober and committed to abstinence when treatment is provided in groups, apparently because of rewarding and therapeutic benefits like affiliation, confrontation, support, gratification, and identification. This capacity of group therapy to bond patients to treatment is an important asset because the greater the amount, quality, and duration of treatment, the better the client s prognosis (Leshner 1997; Project MATCH Research Group 1997). The primary audience for this TIP is substance abuse treatment counselors; however, the TIP should be of interest to anyone who wants to learn more about group therapy. The intent of the TIP is to assist xv

19 counselors in enhancing their therapeutic skills in regard to leading groups. The consensus panel for this TIP drew on its considerable experience in the group therapy field. The panel was composed of representatives from all of the disciplines involved in group therapy and substance abuse treatment, including alcohol and drug counselors, group therapists, mental health providers, and State government representatives. This TIP comprises seven chapters. Chapter 1 defines therapeutic groups as those with trained leaders and a primary intent to help people recover from substance abuse. It also explains why groups work so well for treating substance abuse. Chapter 2 describes the purpose, main characteristics, leadership, and techniques of five group therapy models, three specialty groups, and groups that focus on solving a single problem. Chapter 3 discusses the many considerations that should be weighed before placing a client in a particular group, especially keying the group to the client s stage of change and stage of recovery. This chapter also concentrates on issues that arise from client diversity. Chapter 4 compares fixed and revolving types of therapy groups and recommends ways to prepare clients for participation: pregroup interviews, retention measures, and most important, group agreements that specify clients expectations of each other, the leader, and the group. Chapter 4 also specifies the tasks that need to be accomplished in the early, middle, and late phases of group development. Chapter 5 turns to the stages of treatment. In the early, middle, and late stages of treatment, clients conditions will differ, requiring different therapeutic strategies and approaches to leadership. Chapter 6 is the how-to segment of this TIP. It explains the characteristics, duties, and concepts important to promote effective group leadership in treating substance abuse, including how confidentiality regulations for alcohol and drug treatment apply to group therapy. Chapter 7 highlights training opportunities available to substance abuse treatment professionals. The chapter also recommends the supervisory group as an added measure that improves group leadership and gives counselors in the group insights about how clients may experience groups. Throughout this TIP, the term substance abuse has been used to refer to both substance abuse and substance dependence (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision [DSM-IV-TR] [American Psychiatric Association 2000]). This term was chosen partly because substance abuse treatment professionals commonly use the term substance abuse to describe any excessive use of addictive substances. In this TIP, the term refers to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders described by DSM-IV. The sections that follow summarize the content in this TIP and are grouped by chapter. Groups and Substance Abuse Treatment Because human beings by nature are social beings, group therapy is a powerful therapeutic tool that is effective in treating substance abuse. The therapeutic groups described in this TIP are those groups that have trained leaders and a specific intent to treat substance abuse. This definition excludes self-help groups like Alcoholics Anonymous and Narcotics Anonymous. Group therapy has advantages over other modalities. These include positive peer support; a reduction in clients sense of isolation; real-life examples of people in recovery; help xvi Executive Summary

20 from peers in coping with substance abuse and other life problems; information and feedback from peers; a substitute family that may be healthier than a client s family of origin; social skills training and practice; peer confrontation; a way to help many clients at one time; structure and discipline often absent in the lives of people abusing substances; and finally, the hope, support, and encouragement necessary to break free from substance abuse. Groups Commonly Used in Substance Abuse Treatment Five group models are common in substance abuse treatment: Psychoeducational groups, which educate clients about substance abuse Skills development groups, which cultivate the skills needed to attain and sustain abstinence, such as those needed to manage anger or cope with urges to use substances Cognitive behavioral groups, which alter thoughts and actions that lead to substance abuse Support groups, which buoy members and provide a forum to share pragmatic information about maintaining abstinence and managing day-to-day, chemical-free life Interpersonal process groups, which delve into major developmental issues that contribute to addiction or interfere with recovery Three other specialized types of groups that do not fit neatly into the five-model classification nonetheless are common in substance abuse treatment. They are designed specifically to prevent relapse, to bring a specific culture s healing practices to bear on substance abuse, or to use some form of art to express thoughts that otherwise would be difficult to communicate. Groups also can be formed to help clients who share a specific problem, such as anger or shyness, that contributes to their substance abuse. Criteria for the Placement of Clients in Groups Not everyone is suited to every kind of group. Moreover, because recovery is a long, nonlinear process, the type of therapy chosen always should be subject to re-evaluation. Appropriate placement begins with a thorough assessment of the client s needs, desires, and ability to participate. Evaluators rely on forms and interviews to determine the client s level of interpersonal functioning, motivation to abstain, stability, stage of recovery, and expectation of success in the group. Most clients can function in a group that is heterogeneous, that is, members may be mixed in age, gender, culture, and so on. What is essential, however, is that all clients in a group should have similar needs. Some clients, such as those with a severe personality disorder, will need to be placed in homogeneous groups, in which members are alike in some way other than their dependence problem. Such groups may include people of a particular ethnicity, all women, or a particular age group. Some clients probably are not suitable for certain groups, or group therapy in general, including People who refuse to participate People who cannot honor group agreements, including preserving privacy and confidentiality of group members in accordance with the Federal regulations (42 C.F.R., Part 2) People who make the therapist very uncomfortable People who are prone to dropping out or who continually violate group norms People in the throes of a life crisis People who cannot control impulses People who experience severe internal discomfort in groups Executive Summary Professional judgment is also essential and should consider characteristics such as subxvii

21 stances abused, duration of use, treatment setting, and the client s stage of recovery. For example, a client in a maintenance stage may need to acquire social skills for interacting in new ways, address emotional difficulties, or become reintegrated into a community or culture of origin. Ethnicity and culture can have a profound effect on treatment. The greater the mix of ethnicities in a group, the more likely it is that biases will emerge and require mediation. Special attention may be warranted, too, if clients do not speak English fluently because they may be unable to follow a fast-flowing discussion. Programs should ensure that group members are fluent in the language for their specific demographic area, which may or may not be English. Further, while it might be desirable to match the group leader and all group members ethnically, the reality is that it is seldom feasible. Thus, it is crucial for the group leader to understand how ethnicity affects substance abuse and group participation. Group Development and Phase-Specific Tasks Group membership may be fixed, with a stable and relatively small number of clients. Alternatively, membership may revolve, with new members entering a group when they are ready for the service it provides. Either type can run indefinitely or for a set time. The preparation of clients for group participation commences when the group leader meets individually with each prospective group member to begin to form a therapeutic alliance, reach consensus on what is to be accomplished in therapy, educate the client about group therapy, allay anxiety related to joining a group, and explain the group agreement. In these pregroup interviews, it is important to be sensitive to people who differ significantly from the rest of the group whether by age, ethnicity, gender, disorder, and so on. It is important to assure clients that a difference is not a deficit and can be a source of vitality for the group. Selection of group members is based on the client s fit with a specific group modality. Considerations include the client s Level of interpersonal functioning, including impulse control Motivation to abstain from drug or alcohol abuse Stability Stage of recovery Expectation of success Throughout the initial group therapy sessions, clients are particularly vulnerable to relapse and discontinuation of treatment. The first month appears to be especially critical (Margolis and Zweben 1998). Retention rates in a group are enhanced by client preparation, maximum client involvement, feedback, prompts to encourage attendance, and the provision of wraparound services (such as child care and transportation). The timing and duration of groups also affect retention. While group leaders have many responsibilities in preparing clients for participation in groups, clients have obligations, too. A group agreement establishes the expectations that group members have of each other, the leader, and the group itself. It specifies the circumstances under which clients may be barred from group and explains policies regarding confidentiality, physical contact, substance use, contact outside the group, group participation, financial responsibility, and termination. A group member s acceptance of the contract prior to entering a group has been described as the single most important factor contributing to the success of outpatient therapy groups. The tasks in the beginning phase of a group include introductions, review of the group agreement, establishment of an emotionally safe environment and positive group norms, and focusing the group toward its work. In the middle phase, clients interact, rethink their behaviors, and move toward productive change. The end phase concentrates on reaching closure. xviii Executive Summary

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